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Prevalence of gluteus medius weakness in people with chronic low back pain
compared to healthy controls

Article  in  European Spine Journal · May 2015

DOI: 10.1007/s00586-015-4027-6 · Source: PubMed

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Eur Spine J
DOI 10.1007/s00586-015-4027-6
ORIGINAL ARTICLE
Prevalence of gluteus medius weakness in people with chronic low
back pain compared to healthy controls
Nicholas A. Cooper1,2 • Kelsey M. Scavo1 • Kyle J. Strickland1 • Natti Tipayamongkol1
Jeffrey D. Nicholson2 • Dennis C. Bewyer2 • Kathleen A. Sluka1
Received: 13 May 2014 / Revised: 13 May 2015 / Accepted: 13 May 2015
Ó Springer-Verlag Berlin Heidelberg 2015
Abstract
Purpose Clinical observation suggests that hip abductor
weakness is common in patients with low back pain (LBP).
The purpose of this study is to describe and compare the
prevalence of hip abductor weakness in a clinical popula-
tion with chronic non-specific LBP and a matched sample
without LBP.
Methods One hundred fifty subjects with chronic non-
specific LBP and a matched cohort of 75 control subjects
were recruited. A standardized back and hip physical exam
was performed. Specifically tensor fascia lata, gluteus
medius, and gluteus maximus strength were assessed with
manual muscle testing. Functional assessment of the hip
abductors was performed with assessment for the presence
of the Trendelenburg sign. Palpation examination of the
back, gluteal and hip region was performed to try and re-
produce the subject’s pain complaint. Friedman’s test or
Cochran’s Q with post hoc comparisons adjusted for
multiple comparisons was used to compare differences
between healthy controls and people with chronic low back
pain for both the affected and unaffected sides. Mann–
Whitney U was used to compare differences in prevalence
between groups. Hierarchical linear regression was used to
identify predictors of LBP in this sample.
Results Gluteus medius is weaker in people with LBP
compared to controls or the unaffected side (Friedman’s
& Nicholas A. Cooper
nicholas-cooper@uiowa.edu
1 shown to improve pain and disability in people with LBP
Department of Physical Therapy and Rehabilitation Science,
Carver College of Medicine, University of Iowa, Iowa City,
IA 52242, USA
2
Department of Rehabilitation Therapies, University of Iowa
Hospitals and Clinics, Iowa City, IA 52242, USA
•
test, p \ 0.001). The Trendelenburg sign is more prevalent
in subjects with LBP than controls (Cochran’s Q,
p \ 0.001). There is more palpation tenderness over the
gluteals, greater trochanter, and paraspinals in people with
low back pain compared to controls (Cochran’s Q,
p \ 0.001). Hierarchical linear regression, with BMI as a
covariate, demonstrated that gluteus medius weakness, low
back regional tenderness, and male sex were predictive of
LBP in this sample.
Conclusion Gluteus medius weakness and gluteal muscle
tenderness are common symptoms in people with chronic
non-specific LBP. Future investigations should validate
these findings with quantitative measures as well as in-
vestigate the effect of gluteus medius strengthening in
people with LBP.
Keywords Low back pain
Gluteus medius
Hip
abductor
Muscle pain
Muscle tenderness
Muscular
weakness
Introduction
Low back pain (LBP) was recently reported to be the single
largest cause of disability across the globe [1]. Current
interdisciplinary practice guidelines show strong evidence
for exercise as an intervention for LBP and thus recom-
mend exercise for management of both acute and chronic
LBP [2, 3]. A variety of exercise interventions have been
studied in randomized controlled trials and have been
[4, 5]. Despite this support, it remains unclear which ex-
ercise interventions are optimal in people with chronic LBP
[5]. Current physical therapy guidelines suggest several
possible exercise treatment strategies depending on the
123

patient’s presentation [6]. Most patients with long-standing
LBP are matched to exercise treatment based on the phy-
sical therapy evaluation. Specifically, exercise interven-
tions provided by physical therapists typically focus on the
abdominal and lumbar musculature strength or directional
preference exercises [6–8].
An alternative to these interventions may be to focus on
the hip abductor musculature. Simons and Travell describe
myofascial pain from the gluteus medius muscle as a
common component of LBP [9]. Subsequently, Njoo and
van der Does reported a higher prevalence of gluteus
medius myofascial trigger points in people with LBP [10].
We also suggested gluteus medius weakness is associated
myofascial pain and trochanteric bursitis is a common
clinical presentation in people with LBP [11]. In addition
to myofascial pain, weakness of hip abductors has been
described in LBP when compared to healthy controls [12–
14]. Further, asymmetry in hip abductor strength has been
correlated with increased likelihood to seek care for LBP in
collegiate athletes and we reported gluteus medius weak-
ness was associated with onset of LBP during pregnancy
[15, 16]. More recently Nelson-Wong and colleagues re-
ported that subjects who developed LBP during an ex-
perimental standing task had a different recruitment pattern
of gluteus medius muscle compared to those who did not
develop LBP [17]. Although these findings are suggestive
of hip abductors playing a role in LBP, it is unclear what
proportion of the population with LBP presents with hip
abductor weakness and associated symptoms when com-
pared to healthy controls as well as which hip abductor
muscles are weak.
In this study, we quantified the prevalence of hip muscle
weakness and tenderness of the hip and low back in people
with chronic non-specific LBP. We hypothesized that
gluteus medius weakness and tenderness occurs in the
majority of people with non-specific chronic LBP com-
pared to people without LBP.
Methods
Subjects
Two groups of subjects were recruited. One hundred fifty
people seeking care for LBP lasting longer than 3 months
at the University of Iowa Spine Center Physical Therapy
Clinic were serially recruited at time of presentation to the
clinic. Subjects were recruited if they had non-specific
LBP, defined as pain anywhere from the inferior rib margin
to the gluteal fold, for more than 3 months [18]. Subjects
with a defined etiology, including radiculopathy, neuro-
genic claudication, fracture, primary or secondary spinal
tumors, or other specific pathology, were excluded. One
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Eur Spine J
hundred fifty-one subjects were approached and agreed to
participate with one subject withdrawing after participa-
tion. After recruitment of the LPB group, an age and sex-
matched cohort of 75 control subjects was recruited. Sub-
jects were questioned about their personal history with
LBP: only subjects reporting no to having current LBP and
no to having a history of more than 3 months of LBP were
included. Two subjects were excluded for histories of more
than 3 months of LBP. The University of Iowa Institutional
Review Board approved this study and informed consent
was obtained from all subjects.
Screening examination
All subjects were screened for exclusionary diagnoses with
a standardized history and physical examination. This in-
cluded questions screening for lower extremity paresthesia
and weakness, bowel and bladder dysfunction, pre-
dominant lower extremity pain with standing and walking,
history of trauma, presence of systemic illness, weight loss,
and predominant night pain. The physical examination
screening included assessment for reflex asymmetry, my-
otomal weakness, sensory disturbance, straight leg raise,
and groin pain with hip internal rotation. Subjects were
excluded if screening was suggestive of specific pathology.
Potential control subjects were screened identically and
additionally were excluded if they presented with either
acute or chronic low back pain.
Muscle strength
Gluteus medius, TFL, and gluteus maximus manual muscle
tests (MMTs) were performed using break tests as de-
scribed by Hislop and Montgomery [19]. Gluteus medius
strength was tested by placing subject in side-lying and
having the subject abduct and slightly extend the hip while
keeping the pelvis rotated slightly forward. Resistance was
applied at the ankle. TFL strength was tested by position-
ing the subject in side-lying with the limb to be tested
flexed at the hip. The hip was abducted in this flexed po-
sition and resistance was applied at the ankle. Gluteus
maximus strength was tested positioning the subject in
prone with the knee flexed, then hip was extended with the
knee remaining flexed and resistance was applied at the
posterior thigh just above the knee. MMTs were scored
using the criteria defined by Hislop and Montgomery [19].
If the subject was able to resist maximal resistance they
were scored 5/5, if they broke against resistance: 4/5; if
they were unable to tolerate resistance, but could move
against gravity: 3/5; if they could move the limb when
positioned to minimize the effect of gravity: 2/5; palpable
contraction, but no movement: 1/5, and no palpable ac-
tivity: 0/5.
Eur Spine J
Trendelenburg sign
The Trendelenburg sign was assessed as a functional
measure of gluteus medius strength [20]. This was per-
formed as outlined by Hardcastle and Nade [21]. Subjects
stood with the examiner behind them, observing the iliac
crests visually and with palpation, and were instructed to
lift one foot off the ground by flexing the hip. The sign was
considered absent if the subject was able to maintain the
pelvis in neutral or with the non-stance side elevated and
present if the subject was unable to maintain the pelvis
level or had to shift the trunk to keep the pelvis level.
Tenderness
The gluteals, greater trochanters, lumbar paraspinals, and
piriformis were palpated for tenderness bilaterally. Gluteus
medius was palpated from its distal insertion at the greater
trochanter over the muscle belly toward the posterior su-
perior iliac spine (PSIS) and then over its proximal at-
tachment along the ilium just inferior to the iliac crest.
Gluteus maximus was palpated at its origin along the pos-
terior ilium and lateral sacrum, then over the muscle belly to
its distal insertion at the iliotibial band inferior to the greater
trochanter. The greater trochanters were palpated most
laterally initially and then posteriorly and superiorly to the
apex of the trochanter. The lumbar paraspinals were pal-
pated from just medial to the PSIS superiorly to the thorax.
Palpation of the piriformis was attempted from its lateral
insertion at the greater trochanter, over the muscle belly,
toward its origin on the sacrum. Tenderness was defined as
reproduction of the subject’s pain complaint when using
enough pressure to blanch the examiner’s nail.
Inter-rater reliability
Inter-rater reliability was assessed between all four asses-
sors. Assessors had 1–40 years in performing these
assessments. All assessors independently and in random
order assessed a series of six female pilot subjects with a
mean age of 30 years, three with LBP and three without
LBP, using the above described MMT, Trendelenburg sign,
and muscle tenderness examination. The examiners were
blinded to the presence of LBP in these subjects.
Data analysis
Data from subjects with chronic LBP were divided into
affected and unaffected sides based on the location of their
symptoms. Subjects with bilateral complaints were treated
as both sides being affected sides. The percentage of sub-
jects with each symptom was calculated. Age, height,
weight, and BMI were compared with independent samples
t tests. Inter-rater reliability of MMT, Trendelenburg sign,
and palpation tenderness was assessed with a two-way
random effects model. Manual muscle testing results be-
tween groups and side were assessed with Friedman’s test
with post hoc comparisons adjusted for multiple compar-
isons. The presence of the Trendelenburg sign and palpa-
tion tenderness were assessed between groups and side
using Cochran’s Q corrected for multiple comparisons.
A Mann–Whitney U was used to compare differences in
prevalence between groups. A receiver operating charac-
teristic (ROC) curve was generated to determine the ap-
propriate cut off for MMT scores for determining weakness
in the total sample population. A hierarchical linear re-
gression was performed to identify predictors of the pres-
ence of LBP in the total sample population. Any
demographic differences between samples were treated as
covariates. Potential predictors included age, sex, BMI,
presence of gluteus medius weakness, low back regional
tenderness to palpation, and the presence of Trendelenburg
sign. Regression was performed in both forward and
backward methods using p \ 0.05 as entry criterion and
p [ 0.1 as exit criterion. Significance was set at p = 0.01
for all tests. SPSS 21 was used for all analyses.
Results
One hundred fifty subjects with chronic LBP and 75 age
and sex-matched control subjects were recruited and en-
rolled. Characteristics of both groups are presented in
Table 1. Subjects with chronic LBP had a higher BMI.
Eighty-four subjects with LBP had unilateral symptoms
and 66 had bilateral symptoms, totaling 216 affected and
84 unaffected sides. Interclass correlation coefficient for
MMT was 0.597 (0.331–0.774, 95 % CI). There was per-
fect reliability among Trendelenburg sign and muscle
tenderness examination.
There were significant main effects for MMT of the
gluteus medius, TFL, and gluteus maximus (Friedman’s
test, all p \ 0.001) (Fig. 1). A significant decrease in glu-
teus medius strength was observed for the affected side
(MMT grade ± SD, 3.35 ± 0.73) compared to the unaf-
fected side (4.56 ± 0.66, p \ 0.001) or control group
(4.46 ± 0.50, p \ 0.001). TFL strength was significantly
greater on the unaffected side (4.93 ± 0.26) compared to
controls (4.48 ± 0.50, p \ 0.001), but not the affected side
(4.81 ± 0.44). There were no significant differences in
gluteus maximus strength. There was a significant main
effect for the Trendelenburg sign between groups
(Cochran’s Q, p \ 0.001). The Trendelenburg sign was
more frequently present on the affected side (54.2 %)
compared to the unaffected side (7.1 %, p \ 0.001) or
controls (9.7 %, p \ 0.001) (Fig. 1d).
123
 Eur Spine J

Table 1 Subject characteristics

Chronic LBP (n = 150) Control (n = 75) t test
are mean ± standard deviation
Age (years) 41.4 ± 13.0 40.7 ± 13.9 0.329, p = 0.743
Sex (% female) 64.7 65.3
Height (cm) 169.4 ± 11.4 168.2 ± 9.4 0.801, p = 0.424
Weight (kg) 84.9 ± 22.2 73.2 ± 21.2 3.623, p \ 0.001
BMI (kg/m2) 29.6 ± 7.2 25.8 ± 7.0 3.543, p \ 0.001
Only weight and BMI were significantly different between groups

A 5 B 5
+
G. Medius MMT (0-5)

4 4
*

TFL MMT (0-5)

3 3

2 2

1 1

0 0
Affected Unaffected Control Affected Unaffected Control

C 5 D 100
90
(+) Trendelenburg (%)

80
G. Maximus MMT (0-5)

4
70
3 60
50
*
2 40
30
1 20
10
0 0
Affected Unaffected Control Affected Unaffected Control

Fig. 1 Gluteus medius strength is significantly less on the affected (?p \ 0.001). Trendelenburg sign is significantly more prevalent on
side compared to the unaffected side or controls (*p \ 0.001). TFL the affected side compared to both the unaffected side and controls
strength is greater on the unaffected side compared to controls (*p \ 0.001)

There was a significant difference for the presence of
palpation tenderness between groups (Mann–Whitney U,
p \ 0.001) (Fig. 2a). There were significant main effects
for palpation tenderness over the gluteals, greater tro-
chanter, and lumbar paraspinals (Cochran’s Q, p \ 0.001)
(Fig. 2b–d). Gluteal tenderness was more prevalent on the
affected side (68.1 %) compared to the unaffected side
(4.8 %, p \ 0.001) or controls (11.2 %, p \ 0.001).
Similarly, there was more frequent tenderness over the
greater trochanter on the affected side (44.9 %) compared
to the unaffected side (6.0 %, p \ 0.001) or controls
(6.0 %, p \ 0.001). Lumbar paraspinal tenderness was
more prevalent on the affected side (53.2 %) compared to
the unaffected side (23.8 %, p \ 0.001) or the controls
(0.7 %, p \ 0.001), as well as being different between the
unaffected side and controls (p = 0.006). There was no
significant difference in piriformis tenderness.
The ROC curve demonstrated that an MMT score of B3/
5 was the optimal cut point for using gluteus medius
weakness to determine the presence of LBP from the total
sample (Fig. 3). The presence of LBP was correlated with
higher BMI, gluteus medius weakness, low back tender-
ness, and a positive Trendelenburg sign (Table 2). Subse-
quent hierarchical linear regression found that higher BMI,
gluteus medius weakness, low back regional tenderness,
and male sex as predictors of LBP across this sample
(Table 3). The strongest contributor was gluteus medius
weakness (DR2 = 0.461, p \ 0.001) while the other

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Eur Spine J

A 100
B 100

TTP over Gluteals (%)

90 * 90

Low Back TTP (%)

80 80
70 70 *
60 60
50 50
40 40
30 30
20 20
10 10
0 0
LBP Control Affected Unaffected Control
C D
100 100

TTP over Paraspinals (%)

TTP over Trochanter (%)

90 90
80 80
70 70
60 60
50 50 *
40
* 40
30 30 +
20 20
10 10
0 0
Affected Unaffected Control Affected Unaffected Control

Fig. 2 Low back tenderness is more prevalent in subjects with LBP both the unaffected side and controls (*p \ 0.001). There is more
(*p \ 0.001). Tenderness is more prevalent over the gluteals, greater paraspinal tenderness on the unaffected side compared to controls
trochanter, and lumbar paraspinals on the affected side compared to (?p = 0.001)

1.0 However, only the gluteus medius weakness was a sig-

3/5 or less MMT
0.9 nificant predictor of the presence of LBP when compared
0.8 to the controls. Future studies will need to confirm this
0.7 subgroup in other settings and determine if treatment of the
gluteus medius weakness has a positive effect on
Sensitivity

0.6
4/5 or less MMT symptoms.
0.5
Our data agree with prior studies showing relative hip
0.4
abductor weakness in subjects with LBP compared to
0.3
controls [13, 14]. Both of these studies look at hip ab-
0.2
duction in the frontal plane with contributions from the
0.1 TFL and gluteus medius. Neither study assessed the com-
0.0 posite abduction and extension that is performed by the
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
1-Specificity
gluteus medius with minimal TFL contributions [19]. The
current study was specifically designed to separate out the
Fig. 3 Using a cutoff of 3/5 or less on gluteus medius strength testing contribution of the TFL from the gluteus medius by at-
was most accurate in the assessment of LBP in this sample tempting to evaluate each individually. Our results
demonstrated no difference in TFL strength between con-
variables explained substantially less of the variability trols and the affected side of subjects with LBP, but sig-
(DR2 \ 0.1, p B 0.001). nificant weakness in the gluteus medius in subjects with
LBP. Thus, the current study suggests gluteus medius
muscle weakness contributes to the presentation of chronic
Discussion non-specific LBP. Reproduction of these results with a
quantitative strength assessment such as dynamometry
The current study identifies a sub-population of patients could be used to confirm the current results. Further the
with chronic non-specific LBP with signs of hip abductor effects of treatment of the gluteus medius muscle weakness
dysfunction: significant gluteus medius weakness (B3/5 on LBP itself would further help determine the relevance of
MMT), gluteal tenderness, and the Trendelenburg sign. the weakness to the pain itself. Additionally, there may be

123
 Eur Spine J

Table 2 The presence of LBP was correlated with higher BMI, gluteus medius muscle weakness, low back regional tenderness and a positive
Trendelenburg sign
LBP Age Sex BMI G medius weak Low back tender

Age 0.021, p = 0.754

Sex 0.083, p = 0.221 -0.072, p = 0.291
BMI 0.281, p \ 0.001 0.0199, p = 0.003 0.051, p = 0.455
G medius weak 0.723, p \ 0.001 0.004, p = 0.959 -0.084, p = 0.216 0.213, p = 0.002
Low back tender 0.672, 0 \ 0.001 0.052, p = 0.448 -0.078, p = 0.252 0.298, p \ 0.001 0.667, p \ 0.001
Trendelenburg 0.452, p \ 0.001 0.082, p = 0.230 -0.027, p = 0.688 0.075, p = 0.269 0.568, p \ 0.001 0.505, p \ 0.001

Table 3 Hierarchical linear

Beta Standard error t p Partial R2 Model R2
regression with BMI as a
covariate Constant 0.061 0.083 0.739 0.461 0.615
BMI 0.005 0.003 1.527 0.128 0.079
G medius weakness 0.465 0.053 8.763 \0.001 0.461
Low back tender 0.317 0.057 5.601 \0.001 0.054
Male sex 0.146 0.042 3.445 0.001 0.022
Gluteus medius weakness is the strongest predictor of LBP. Low back tenderness and male sex also were
predictive of LBP

some amount of gluteus medius muscle weakness in the
population in general. A large proportion of our control
population scored only 4/5 on MMT of gluteus medius
muscle and thus this could be a potential risk factor for
development of non-specific LBP.
Others have also suggested that gluteus medius dys-
function plays a role in LBP. Simons and Travell described
gluteus medius muscle referred pain as a component of
LBP [9]. Nadler and colleagues demonstrated a higher
likelihood of onset of LBP in female athletes with hip
abductor strength differences between sides [16]. Nelson-
Wong and colleagues demonstrated gluteus medius co-ac-
tivation as a predictor of onset LBP during an experimental
standing task [17]. Together these data suggest that gluteus
medius muscle may play a significant role in chronic LBP.
However, it is unclear if initial gluteus medius muscle
weakness is a cause or consequence of LBP as well as how
to manage this observed dysfunction.
Current physical therapy management of patients with
LBP is guided by a treatment-based classification system
that attempts to match subgroups of patients with the in-
terventions that lead to the best outcomes [6]. Much of this
work has focused on acute LBP; patients with chronic LBP
do not readily fit into this classification system [22]. A
recent review of classification systems for chronic LBP
found strong evidence to support the reliability of only two
systems: the McKenzie and the movement impairment
classification systems [23]. They also report some evidence
to support the effectiveness of the McKenzie classification
system [23]. There does not exist a comprehensive classi-
fication system that directs intervention and successfully
predicts outcome. One of the difficulties in directing ex-
ercise treatment in chronic LBP may be the broad effect of
any exercise intervention.
Most exercise interventions in chronic LBP populations
are effective [4]. The most recent Cochrane meta-analysis
of exercise in LBP found that individually prescribed ex-
ercise interventions that included strengthening and stabi-
lization exercises were most common in chronic LBP
populations [24]. These exercise interventions were con-
cluded to be effective in improving pain and function in
chronic LBP [24]. This finding was reiterated in the clinical
practice guidelines from the American Pain Society and
American College of Physicians [3]. However, they do not
differentiate between choices of exercise intervention [3].
One of the chief reasons for the paucity of advice regarding
specific exercise selection is the poor description of exer-
cise interventions in the literature. Future experiments
should examine specific populations with well-described
targeted exercise programs [24]. We believe patients with
chronic non-specific LBP who present with gluteus medius
weakness and associated tenderness may represent a
treatment subgroup that could benefit from targeted gluteus
medius strengthening. A preliminary study of ten subjects
with non-specific LBP treated with 3 weeks of hip abductor
strengthening reduced pain by 48 %, but was not statisti-
cally significant [14]. Future clinical studies will need to
confirm that gluteus medius strengthening produces

123
Eur Spine J
superior results than other forms of exercise in this sub-
group of patients with chronic LBP.
The current study demonstrated a statistical difference in
TFL strength between the unaffected side of subjects with
LBP and control subjects. The assessed strength values are
extremely close: 4.48 in the controls and 4.93 in the sub-
jects with LBP on the unaffected side. Although this dif-
ference reached statistical significance we believe this does
not represent a clinically significant difference, especially
given the lack of objective criteria for MMT grades above
3/5 [19]. Use of dynamometry may better evaluate this
apparent difference in muscle strength.
There are several limitations in this study. The clinical
sample was recruited from one specialty physical therapy
clinic in a major university hospital. The population re-
ferred to our clinic may be uniquely different than those
seen in a general practice. Therefore, future studies should
confirm this distribution of subjects across other practice
settings. Although our controls were matched by age and
sex to the clinical sample, they had a lower BMI. It is
possible that our control subjects were healthier or more
physically active and thus stronger. The assessments we
used are performed routinely in clinical settings; however,
they have limited objectivity. The high inter-rater re-
liability for tenderness and Trendelenburg sign may rep-
resent extensive training of our examiners prior to data
collection. While inter-rater reliability of MMT is low,
this is similar to prior reports [25]. Further, we ac-
knowledge that MMT used clinically is an indirect mea-
sure of muscle function and not as strong as dynamometry
[26]. Using palpation, a commonly used clinical measure,
is similarly less specific than using pressure pain thresh-
olds, which could be confirmed with pressure algometry.
Future studies should utilize quantitative assessments
such as pressure algometry to measure pain thresholds,
dynamometry to measure muscle strength, and elec-
tromyography to examine muscle activation patterns to
directly compare and confirm the clinical measures of
palpation tenderness and MMT. Future studies should also
determine if strengthening of the gluteus medius muscle
will alleviate LBP symptoms and which of these measures
individually or in combination predicts outcomes to
treatment.
Conclusion
Gluteus medius muscle weakness and associated tender-
ness is a common presentation in people with chronic non-
specific LBP. Focusing on assessment and treatment of
gluteus medius muscle dysfunction may allow for better
clinical decision-making and better treatment outcomes for
people with LBP.
Acknowledgments This work was supported by the Department of
Rehabilitation Therapies at the University of Iowa Hospitals and
Clinics; the Department of Physical Therapy and Rehabilitation Sci-
ence at the Carver College of Medicine at the University of Iowa; and
the National Center for Research Resources and the National Center
for Advancing Translational Sciences, National Institutes of Health,
through grant UL1RR024979.
Conflict of interest None.
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